“The barriers to obtaining a buprenorphine (Suboxone) waiver in the U.S. are small, but loom large in many physicians’ minds.

Only 46,500 — about 5% of the nation’s doctors — have waivers to prescribe buprenorphine, a medication used to treat opioid addiction. While that number has grown in recent years, it includes psychiatrists and addiction specialists, many of whom don’t practice in rural areas.

But even including those specialties, it’s not enough. “The current number of waivered physicians is not sufficient to ensure access to buprenorphine treatment for all individuals with opioid use disorder, even if every physician were prescribing at the maximum of their waivers,” said Hannah Knudsen, PhD, of the University of Kentucky College of Medicine in Lexington. Knudsen has studied the relationship between the supply of buprenorphine-waivered physicians and prescription opioid mortality.”

Boston is not the only city with a powerful push by academics and providers for medication-assisted treatment (MAT), but it’s definitely one with a high profile. We talked with Janice F. Kauffman, RN, MPH, and Sarah Wakeman, MD, about how opioid treatment programs (OTPs), specifically, can help fight stigma against MAT.

Education is important, but by itself won’t work because of pre-existing bias, said Ms. Kauffman, who is vice president of Addiction Treatment Services for North Charles Foundation, Inc., director of addictions consultation for the Department of Psychiatry, Cambridge Health Alliance, and assistant professor of Psychiatry, Harvard Medical School. “I spend a good amount of my time talking to community members, talking to police, trying to educate people in the community,” Ms. Kauffman told AT Forum. “But I don’t think education is as helpful as we hope it will be, because people come with pre-existing opinions.”

In other words, if someone is predisposed to believe methadone is “trading one addiction for another,” that person will believe it, regardless of the information they are given.

Teaching Police

“I often teach police officers,” said Ms. Kauffman. “And I’m impressed that I can spend an hour giving them information—in particular, about the efficacy of methadone maintenance. But at the end of the day there are many who maintain that you should be off the medication, that this isn’t really a disease like other diseases.”

One problem is that substance use disorders are still conflated with crime, in the mind of many in law enforcement. Those people don’t need to be educated about cancer, dental caries, or other diseases. Perhaps it’s too much of a stress to even try to educate them about addiction—but, in fact, many police officers, especially in Massachusetts, the home of PAARI (Police Assisted Addiction and Recovery Initiative), would rather help people get treatment than arrest them. The question is, what kind of treatment? Massachusetts currently has an initiative focused on getting residential treatment for people with opioid use disorders, and favoring antagonist treatment with Vivitrol instead of buprenorphine or methadone. This is also true for people under civil commitment—a process that falls in line with many beliefs of law enforcement.

The Media

Janice F. Kauffman, RN, MPH

Ms. Kauffman also said that OTPs need to do a better job of educating the media, which is in general not well informed about methadone maintenance, a treatment that’s proven efficacious for decades. “The media does not do us justice,” she said. “Their stories have focused on people who don’t do well.” She added that some stories look at people in the community who are not doing well, mostly because of benzodiazepines and other drugs of misuse. “This is what happened in the Boston area, with stories about what the media dubbed ‘Methadone Mile.’ Even when behavior doesn’t involve methadone, the media automatically connect it. They think that neighborhoods with OTPs are places people deal drugs—but people deal drugs everywhere.”

It would help for successful patients to come forward, but they’re afraid to, because of the effects on their jobs and lives and families, said Ms. Kauffman. “I’ve been doing this work since the early 1970s. I’ve lived this stigma for a long time, and I’ve watched our patients suffer from it.”

Employers

So, what is the solution? Perhaps OTPs should ask employers to publicly support methadone maintenance—“especially employers who are willing to come forward, and who know that their patients are in methadone treatment and doing well. That would be better than putting it on the backs of patients,” said Ms. Kauffman. “Employers could say, ‘Some people who are working for me are methadone patients, and they’re doing very well,’” said Ms. Kauffman. “This would show that people are willing to employ our patients, who have a disease like any other disease.”

The North Charles Foundation produced “Waking Up: A Story in Four Parts,” a short film on its program, specifically designed to address stigma, as part of a grant. In a narrative therapy group in the film, patients told how they got into trouble with drugs, and what methadone treatment was like. (The grant was from Johnson and Johnson, the Harvard Medical School’s division on addictions, and a private family foundation.) “We showed the film to over 100 medical, social-service and substance use treatment providers in the greater Boston area, for a pre-test and a post-test,” said Ms. Kauffman. Before they saw the film, viewers were biased against methadone. After they saw it, their feelings changed. “They were struck by how the patients suffered, and what happened privately in their lives. They were also impressed with how the patients got better, and became contributing members of society.”

Ms. Kauffman uses this film when she teaches doctors training in hospitals as residents. “It’s powerful,” she said.

One Day at a Time

There’s a commonly held notion that methadone maintenance is forever, which can be daunting, creating a stigma of its own. It’s similar to what happens when people with alcohol use disorders are overwhelmed by the idea that they can never drink again. “We have lots of patients who come to treatment saying they want methadone only for a certain period,” said Ms. Kauffman. “I would never say ‘no,’ to that. We say, ‘Let’s get you stabilized, let’s help you look at this.’” Often it’s the stigma that makes patients want to leave treatment quickly.

“If you have to deal with the notion of needing to do this for the rest of your life—that’s hard for patients to wrap their minds around,” she said. But OTPs help new patients normalize their lives as soon as possible, and most patients see that they can have normal, good lives without giving up their medication, and without switching medications.

Sarah Wakeman, MD

Language Counts

Dr. Wakeman, who is medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at Massachusetts General Hospital, co-chair of the Mass General Opioid Task Force, and an assistant professor in medicine at Harvard Medical School, is a big proponent of using proper language to reduce stigma.

“One of the greatest struggles we have is reducing stigma, not just about addiction but about treatment,” she said. “If we change our language, using medically appropriate terminology just as we do for other illnesses, we can change how the rest of the world thinks of treatment.”

A very simple but necessary change is to stop using the terms “clean” and “dirty,” she said. “You can say a toxicology test was positive or negative, or you can say the results are appropriate or inappropriate.” The point is not just to switch the words, it’s to stop being judgmental. “When I talk with a patient about diabetes testing, I refer to results as being within range or out of range. OTP counselors telling patients about a positive drug test can begin by saying, “There were unexpected findings in your toxicology report,” she said. “Stay away from judgement-laden language.”

This isn’t just a matter of being politically correct, said Dr. Wakeman. If treatment programs convey this kind of stigma against patients, how are people supposed to avoid it?

Dr. Wakeman also points out that “dependence” should not be confused with addiction. Being dependent on a medication is not the same as being addicted—it’s not pathological. “If someone is taking long-term opioids appropriately for pain, that person is dependent,” she said. “If someone is taking methadone for addiction, that person is dependent.”

Involving OTPs in the General Medical System

“The more we can engage OTPs in the general medical system, the better for patients,” said Dr. Wakeman. Her facility does not have its own OTP, but works closely with OTPs, she said. “We have agreements with OTPs. It’s important to have these agreements with OTPs as a hospital system,” she said. “That way we can link patients directly into ongoing care. It’s been great for us to work with OTPs.”

In deciding whether to refer a patient to an OTP or to office-based opioid treatment (OBOT) with buprenorphine, Dr. Wakeman said the most important factor is “what the patient wants and what the patient thinks will be effective.” Most patients prefer to start with buprenorphine, said Dr. Wakeman. “But if the patient reports having done well on methadone in the past, we go that way. If someone has tried both in the past, if they’ve done well on one but not the other, that helps us decide.”

Legacy for Methadone

For methadone, Dr. Wakeman uses a 1965 New Yorker profile of Marie Nywswander, MD, who, with Vincent Dole, MD, developed methadone maintenance treatment. Called “The Treatment of Patients,” the profile, by Nat Hentoff, explains how methadone works. “I still use this now, in 2018,” said Dr. Wakeman. “A molecule of methadone is no more problematic than a molecule of insulin.”

Dr. Wakeman has patients who work at Harvard or Mass General and are taking methadone. “You wouldn’t know it,” she said. “These people are doing well and going about their business and living their lives.

“We need to make addiction treatment seem scientific and a part of the medical mainstream,” she said. “And we need to hold them to the same standards and expectations we use for any other treatment provider.”

It would be beneficial to hear more patient narratives of recovery on MAT, said Dr. Wakeman, who agreed with Ms. Kauffman that the media promotes some stigma. “We need to hear from patients on MAT saying, ‘This is how much better my health and my life are now.’”

“The United States Drug Enforcement Administration today announced a deregulatory measure that will make it easier for residents of underserved areas to receive treatment for opioid addiction.

As published today in the Federal Register, nurse practitioners and physician assistants can now become DATA-Waived qualifying practitioners, which gives them authority to prescribe and dispense the opioid maintenance drug buprenorphine from their offices. Prior to the enactment of the Drug Abuse Treatment Act of 2000, only physicians could treat opioid addicts and had to register with DEA as both physicians and operators of Narcotic Treatment Programs. Waiving this second registration prompted more physicians to offer treatment services.

Today’s action brings DEA regulations into conformity with the Comprehensive Addiction and Recovery Act passed by Congress and signed into law in 2016. Because the vast majority of DATA-Waived physicians prior to CARA served urban areas, rural parts of the United States were underserved. This action provides more treatment options for addicts in rural parts of the country.”

“Fewer than one in three rural physicians who have a waiver to prescribe buprenorphine for opioid use disorder currently do so, according to research that recently appeared in Annals of Family Medicine.

Compounding the problem of opioid misuse in rural areas is that 60.1% of nonurban counties lack physicians that have these waivers, hindering treatment in these locations, noted researchers.

“A few studies, limited to one or only a few states, have looked at the barriers physicians face providing buprenorphine maintenance treatment, but none has examined nationally the differences between physician groups who are and are not actively using their waivers or accepting new patients,” C. Holly A. Andrilla, MS, department of family medicine, University of Washington School of Medicine, and colleagues wrote. “This study’s purpose was to understand the barriers physicians with waivers face in providing buprenorphine maintenance treatment.”

“The American Medical Association delayed a measure on Monday that would have allowed physicians to prescribe the drug buprenorphine for the treatment of opioid abuse without obtaining a waiver.

At the AMA’s annual meeting in Chicago, the organization’s House of Delegates voted to refer the proposal for decision at a later time after contentious discussion among the delegates.

Currently, physicians must obtain a waiver before they can prescribe buprenorphine to treat opioid addiction. Doctors must complete an eight-hour training session and other requirements before receiving the waiver.”

“Confronted by the gravity of an opioid epidemic that contributes to the deaths of 91 Americans daily, the nation’s physicians are making much greater use of state prescription drug-monitoring programs (PDMPs), reducing opioid prescriptions, and increasing prescriptions for the life-saving antidote naloxone. Tens of thousands of physicians nationwide are now certified to provide office-based medication-assisted treatment (MAT) for opioid-use disorders, yet there remains a treatment gap that leaves too many patients who want help unable to get it.

These were some of the key points covered by Patrice A. Harris, MD, chair of the AMA Task Force to Reduce Prescription Opioid Abuse, during a recent talk at the National Rx Drug Abuse & Heroin Summit. The summit, held in Atlanta, is perhaps the nation’s largest and most influential meeting of policymakers, health professionals, law enforcement and public health advocates devoted to addressing the opioid epidemic.

Produced by the American Association for the Treatment of Opioid Dependence (AATOD) under a contract with the Substance Abuse and Mental Health Services Administration, three white papers provide comprehensive models of how opioid treatment programs (OTPs) can ensure high-quality care and continuity of services.

We summarize the white papers in this issue, focusing on the hub-and-spoke model in Vermont. In this model, buprenorphine and office-based opioid treatment are integrated with OTPs, but OTPs perform all inductions and provide specialty care and consultation to the entire system.

The first white paper (56 pages) is called “Models of Integrated Patient Care Through OTPs and DATA 2000 Practices.” The first section of this paper discusses “Essential Elements of Vermont’s Hub and Spoke Health Homes Model,” and was written by Karen Casper and Anthony Folland of the Vermont Department of Health, Agency of Human Services. The second section, by Sue Storti, PhD, RN, is “Integration of Health Homes in Rhode Islands’ OTPs.” The third section covers “Integration of Health Homes in Maryland OTPs,” and was written by Vickie Walters and Angela Fulman.

The second AATOD white paper (34 pages) is “Integrated Service Delivery Models for Opioid Treatment Programs in an Era of Increasing Opioid Addiction, Health Reform, and Parity.” The first section of this publication was written by Kenneth Stoller, MD, and Mary Ann Stephens, MD, of the Department of Psychiatry and Behavioral Sciences, the John Hopkins University School of Medicine. It provides a model for how OTPs can work in conjunction with DATA 2000 practices. The second section was written by Allegra Schorr, President of the New York State Coalition of Medication-Assisted Treatment Providers and Advocates. It is concerned with how OTPs can work with primary health care services.

The third white paper (32 pages) is “Increasing Access to Medication-Assisted Treatment for Opioid Addiction in Drug Courts and Correctional Facilities and Working Effectively with Family Courts and Child Protective Services.” Douglas Marlowe, PhD, Chief of Science, Policy and Law of the National Association of Drug Court Professionals, wrote the first section of this paper, covering working with Drug Courts. The second section delves into working with correctional facilities, and was written by Sarah Wakeman, MD, of the Substance Use Disorder Initiative, Massachusetts General Hospital, and Josiah Rich, MD, MPH, director of the Center for Prisoner Health and Human Rights, Brown University. Pamela Peterson Baston, of Solutions of Substance, Inc., wrote the third section; it discusses how OTPs can work with Family Courts and Child Protective Services.

“Just days after President Obama announced September 18 – 24, 2016, as Prescription Opioid and Heroin Epidemic Awareness Week, the U.S. Department of Health and Human Services (HHS) issued new reporting requirements for practitioners who have been approved to treat up to 275 patients using Buprenorphine products, such as Suboxone and Subutex, in an office setting for opioid and heroin addiction. The rule, entitled “Medication Assisted Treatment for Opioid Use Disorders Reporting Requirements,” follows recent changes in federal law raising the patient limit from 100 to 275 patients per practitioner if the practitioner meets certain conditions. The reporting requirements were issued to assess compliance with the additional responsibilities imposed on those practitioners who are approved for the increased patient limit.

The new rule requires practitioners report three categories of information: (1) annual caseload of patients by month; (2) number of patients provided or referred to behavioral health services; and (3) features of the practitioner’s diversion control plan. While specific requirements for diversion control plans have not been provided, the plans should include procedures calculated to reduce the possibility that controlled substances will be transferred or used illicitly. HHS has emphasized the importance of diversion control plans by requiring practitioners to have a control plan in place before they are eligible to receive approval to increase their patient limit to 275.”

In Vermont’s opioid treatment system, devised ingeniously by Gov. Peter Shumlin with Affordable Care Act funding more than five years ago, opioid treatment programs (OTPs) are the hubs, and office-based physicians prescribing buprenorphine are the spokes.

This hub-and-spoke system has solved two massive problems for office-based opioid treatment (OBOT) providers: 1) the OTPs are the experts in assessment, and decide along with the patient whether methadone in an OTP or buprenorphine in an OBOT setting would be better; and 2) the OTPs are the experts in induction with either medication—buprenorphine or methadone.

Many OBOT physicians without experience treating addiction have been unsure about how to perform this procedure and how to get new patients stable. Primary care physicians in particular are uncomfortable with having patients in withdrawal in their offices, and buprenorphine induction requires that the patient be in mild withdrawal, with logistics often calling for the physician to send the patient home, to return when in withdrawal.

ACA at Work

While the program would be ideal for other states, that might not be a realistic goal. In Vermont, the program is dependent on the health care reform infrastructure, Barbara Cimaglio, deputy commissioner of the state’s Department of Health, explained to AT Forum in an interview in September. “It’s heavily supported by Medicaid, and also by the private insurance companies in Vermont, which cover the hub bundle of services,” she said. “But there are elements of the model that would work well in other places.”

The hub-and-spoke model began with a hub in central Vermont whose role was to perform inductions and get people stabilized, she said. The state also developed buprenorphine regulations for Vermont that were stronger than the federal regulations (DATA 2000) for OBOT, requiring that an assessment be conducted to see if counseling would be necessary.

Now that the program has been off the ground for several years, Vermont no longer has the higher match rate for Medicaid. But the hub-and-spoke system is continuing at full speed ahead.

Every state has a different set of regulations, but it’s possible that an OTP or a chain of OTPs could do something similar to the hub-and-spoke model, said Ms. Cimaglio. “There could be a partnership between an OTP and a group of physicians, and they could form the same kind of model.”

Other states have not committed to the hub-and-spoke initiative, which is costly without the kind of waivers Vermont received from the federal Department of Health and Human Services.

Model is Ideal

In the meantime, Richard A. Rawson, PhD, is interested in assessing the hub-and-spoke model. Dr. Rawson grew up on a dairy farm in Vermont and graduated from the University of Vermont before going on to head UCLA’s Integrated Substance Abuse Programs (from which he is now retired). He reportedly plans to retire in Vermont. After spending decades setting up OTPs in California, he returned to Vermont and was astounded by the extent of the opioid problem there, he told the Valley News last month. Later this year, Dr. Rawson, in collaboration with the University of Vermont, will begin an assessment of the hub-and-spoke system.

Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), told AT Forum that the hub-and-spoke model is an idea that many OTPs could adopt. They could form partnerships with local physician groups, as Ms. Cimaglio also suggested, and then refer certain patients who would be suitable for OBOT with buprenorphine to those physicians.

And Mario A. Moreno Zepeda, spokesman for the Office of National Drug Control Policy, said that the administration supports “models that integrate care for substance use disorders with mainstream medicine, such as hub and spoke.” He added that many people still do not have access to effective, medication-assisted treatment.

OTPs themselves can dispense and give take-homes for either buprenorphine or methadone. OBOT physicians can dispense and prescribe buprenorphine.

Looking forward, Ms. Cimaglio said it’s time to leave the “traditional OTP” behind, moving towards what the Vermont-style hub could be: part of an integrated health care network. “There are a lot of opportunities for partnerships, with hospitals, with physicians,” she said.

“The Substance Abuse and Mental Health Services Administration (SAMHSA), as part of the US Department of Health and Human Services (HHS), has issued new reporting requirements for physicians who will be authorized to prescribe the opioid use disorder treatment medication buprenorphine at the new limit of 275 patients. The requirements, published on September 27, 2016 in the Federal Register, are a key step in increasing access to medication-assisted treatment for opioid-related disorders.

Under the new rule, physicians prescribing buprenorphine at the maximum patient cap of 275 will be required to complete a SAMHSA reporting form each year. This reporting will help SAMHSA ensure that physicians prescribing at the new higher levels are in compliance with safe and appropriate prescribing practices. Practitioners will be required to report the annual caseload of patients by month, the number of patients provided behavioral health services and referred to behavioral health services, and features of the practitioner’s diversion control plan.